Title Page
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Work Title
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Date of Work
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Permit Number
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Permit Valid From
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Permit Expires
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Work Location
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Authoriser
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Risk Assessment
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Can you fill in the risk assessment for the works prior to starting?
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Field Operatives ID
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Method Statement
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Are you aware of the method statement associated with the HRA?
Emergency Procedures
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Are operatives on site aware of the emergency action plan?
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Please advise the operatives on the emergency action plan.
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Have operatives been briefed on the scope of works?
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Please advise the operatives on the scope of works.
Weather Conditions/ Ground / Timeline
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What is the weather like?
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What type of ground is the HRA on?
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How long are the operatives expected to be on task for?
Equipment
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What additional equipment is required to facilitate working on the HRA?
Scope of Works
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Can you give a brief description of the type of works being carried out?
OH Risks
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Please tick the relevant hazards identified:
- Safe Access/ Egress
- Site Protection / TM
- Rescue Plan
- MEWPS - Task Lighting
- OH Hazards
- Adverse Weather
- Communication
- Gas Test
- Task Lighting
- Enclosed Space Equipment
- Gas Test
- Water Test
- Plant Restrictions
- Waste Plan
UG Risks
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Please tick the relevant hazards identified:
- Safe Access/ Egress
- Site Protection / TM
- Rescue Plan
- MEWPS - Task Lighting
- OH Hazards
- Adverse Weather
- Communication
- Gas Test
- Task Lighting
- Enclosed Space Equipment
- Gas Test
- Water Test
- Plant Restrictions
- Waste Plan
Enclosed Space
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Please tick the relevant hazards identified:
- Safe Access/ Egress
- Site Protection / TM
- Rescue Plan
- MEWPS - Task Lighting
- OH Hazards
- Adverse Weather
- Communication
- Gas Test
- Task Lighting
- Enclosed Space Equipment
- Gas Test
- Water Test
- Plant Restrictions
- Waste Plan
Gully Suck and De-Silt
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Please tick the relevant hazards identified:
- Safe Access/ Egress
- Site Protection / TM
- Rescue Plan
- MEWPS - Task Lighting
- OH Hazards
- Adverse Weather
- Communication
- Gas Test
- Task Lighting
- Enclosed Space Equipment
- Gas Test
- Water Test
- Plant Restrictions
- Waste Plan
Other Precautions
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Please tick the relevant answer appropriate to the HRA:
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Vehicle Restrictions
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Liaise with Local Residents
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Permit/ Warning Notices/ Erecting Barriers
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Access/ Egress Restrictions
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Provide Suitable Traffic Control
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Work Area Prepared and Cleared
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Adequate Task Lighting
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Communication Plan
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Security (Vehicle/Equipment)
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Adequate Supervision
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Emergency Procedures
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Other ( Please Specify)
PPE
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Please advise on the PPE worn by operatives on task:
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Please Tick:
- Hi-Vis Jacket
- Hi-Vis Trousers
- Ear Protection
- Eye Protection
- Safety Footwear
- Safety Helmet
- Gloves
- Headtorch
- Safety Harness/ Lanyard
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What additional PPE is required to complete the HRA safely and efficiently?
Completion of Work
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The work has been completed and the work area and adjacent areas have been thoroughly checked to ensure no hazards remain.
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All equipment and materials have been removed.
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Safety equipment has been returned
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Work site left tidy
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Other (Please Specify)
Responsibilities
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• A General Permit to Work must be sought from an Authorised Person (Manager) when the risk assessment for the task is out of hours.
• Complete the permit and obtain an authorisation and signature from the Authorised Person.
• Communicate the contents of the General Permit to Work, including associated risk assessments and method statements, to site operatives via a pre-job verbal brief.
• Complete the task in compliance with all permit conditions and associated method statements and risk assessments.
• If deviations from the permit are foreseen, stop work and immediately bring these to the attention of the Authorised Person.
• On competition of the work ensure the permit is closed by the Authorised Person
Authorised Person (Manager):
Inform all relevant employees of this procedure and the activities which it covers.
• Implement this procedure.
• Inspect all permits and ensure the activity and associated risks have been controlled and the permit form has been filled out correctly.
• Issue and sign the permit when satisfied that the employees undertaking the task understand the risks and associated control measures.
Only close the permit when it is clear that all conditions of the permit have been fulfilled.
Authorisations
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All signatories to this permit confirm that they understand the precautions to be taken prior to and during the work. The recipient of this permit is responsible for the safety and equipment of all persons involves.
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Task Authorised By
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Please Sign:
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Time
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Supervisor
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Please Sign:
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Time:
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Crew ID
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Operative Name
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Operative Name
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Crew ID
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Operative Name
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Operative Name
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Crew ID
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Operative Name
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Operative Name
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Task Complete:
